Objective To investigate the clinical application effect of microvascular decompression（MVD） via retroauricular transverse incision in supine position in the treatment of hemifacial spasm（HFS）. Methods A retrospective analysis of 42 cases of hemifacial spasm who underwent microvascular decompression from March 2018 to August 2021 in the Department of Neurosurgery of the First Affiliated Hospital of Anhui Medical University was conducted. According to different surgical methods，the patients were divided into control group（n = 27）and observation group（n = 15）. The observation group received a retroauricular transverse incision in supine position， and the control group a straight retrosigmoid sinus incision in lateral position. The differences in hospitalization days，preoperative preparation time，operation time，position ⁃ related complications，surgical complications，and surgical effects were compared between the two groups. Results The preoperative preparation time of observation group and control group was（4.13 ± 2.25）min and（10.15 ± 2.59）min，and the operation time of observation group and control group was（142 ± 14.23）min and（170.37 ± 24.71）min. In position⁃related complications，scalp injury，trunk compression and postoperative neck and shoulder pain caused by head brace and head nail were 0，2 and 3 cases in the observation group and 27，18 and 12 cases in the control group，showing statistical significance （P < 0.05）. There were no significant differences in length of hospital stay，surgical complications and postoperative outcomes between the two groups（P > 0.05）. Conclusion MVD of the supine postauricular transverse incision approach in the treatment of HFS can significantly reduce preoperative preparation time，operation time and postural⁃ related complications，which has practical value.